The present invention pertains to medical electrical leads adapted to be implanted within the body, and particularly to such leads having at least one distal electrode affixed at a site of a body organ, particularly the epicardium of the heart, employing a light-activated adhesive fixation and methods and systems for accessing the site, applying the distal electrode to the site and activating the light-activated adhesive.
In the field of cardiac stimulation, cardiac pacing leads having bipolar and unipolar pace/sense electrodes have long been used in conjunction with implantable pulse generators (IPGs) to conduct pacing pulses or cardioversion/defibrillation shocks generated by the IPG to a site of the heart and cardiac signals from the site to the IPG. Cardioversion/defibrillation leads and pacing leads are typically provided with a passive fixation or an active fixation mechanism at the lead body distal end that is passively or actively engaged with cardiac tissue to anchor a distal tip electrode at a desired site in or on the heart. Passive fixation generally involves an atraumatic fixation lodging the distal electrode against the endocardium or within a coronary blood vessel. Positive or active fixation generally involves a more traumatic penetration of a fixation mechanism into the myocardium from an endocardial or epicardial surface, and the active fixation mechanism commonly comprises a distal electrode.
Endocardial pacing and cardioversion/defibrillation leads having either active fixation or passive fixation mechanisms are implanted by a transvenous route into a heart chamber to locate the distal electrode(s) at a selected site in the heart chamber where an active or passive fixation mechanism is deployed to maintain the electrode affixed at the site. Epicardial leads are implanted by exposure of the epicardium of the heart typically through a limited subxiphoid approach or a more extensive surgical exposure made to perform other corrective procedures. The distal end of the epicardial lead formed with one or two electrodes and an active fixation mechanism supported by an electrode head is affixed to the epicardium. Typically, the active fixation mechanism comprises the single electrode or one of the bipolar electrodes, but can be separate and electrically isolated from the electrodes.
Epicardial pacing and cardioversion/defibrillation leads were the first to be implanted widely, because endocardial leads lacked effective active or passive fixation mechanisms and relied upon relatively stiff lead bodies that cause perforations and dislodgement of the distal electrode(s). Initially, access to the epicardium was made by a thoracotomy or median sternotomy and excision through or removal of the pericardial sac. Typically, pace/sense electrodes penetrated the myocardium and were sutured against the epicardium to maintain fixation. The large patch electrodes of cardioversion/defibrillation electrodes were sutured to the epicardium.
Many improvements were made in epicardial pace/sense leads to minimize surgical trauma of accessing the epicardium and to avoid the need to suture the electrode to the epicardium. Thus, active fixation mechanisms of epicardial pacing leads typically comprise a tissue penetrating, self-affixing mechanism extending away from a support or base or plate of the electrode head. The fixation mechanism is forced into the myocardium typically employing an introduction tool engaging the electrode head until it is fully seated within the endocardium and the plate bears against the epicardium. The plate is typically formed with a tissue ingrowth encouraging fabric or lattice, whereby tissue ingrowth about the plate assists in chronic anchoring to the heart.
Such active fixation mechanisms include a rigid helix having a sharpened tip that is coupled with a lead conductor within the electrode head and extends at a right angle from the plate as typified by the MEDTRONIC(copyright) Model 6917 lead and the leads disclosed in commonly assigned U.S. Pat. Nos. 3,737,579 and 4,010,758. Other variations of such epicardial screw-in leads include multiple co-axial and intertwined helixes or a helix axially surrounding a pin extending coaxially with the helix axis from the electrode head. During implantation, the lead body and electrode head are mounted to an elongated tool, and the sharpened tip of the helix is advanced through the incision to perforate the epicardium. The tool and lead are rotated to screw the helix in until the plate abuts the epicardium, and the electrode head is detached from the tool.
A further epicardial screw-in lead is disclosed in commonly assigned U.S. Pat. No. 4,357,946 wherein the helix is mounted to a gear mechanism within the electrode head. The helix can itself be rotated to screw into the myocardium without rotating or moving the electrode head by a rotation of a removable stylet extending through the length of the lead body and engaging the gear mechanism. Both unipolar and bipolar embodiments are disclosed.
A further active fixation, unipolar, epicardial lead comprises the MEDTRONIC(copyright) Model 6951 lead disclosed in commonly assigned U.S. Pat. No. 4,313,448. The active fixation mechanism comprises forward facing barbed electrode having the tip at a predetermined angle with relation to the shank of the electrode and with respect to a flexible base pad or plate of the electrode head. The plate has a substantially centered hole and a plurality of outer holes for fibrous ingrowth, and the shank of the electrode extends out through the substantially centered hole. The barbed electrode is pushed into the myocardial tissue to the point where the base pad engages against the epicardium thereby indicating full implantation within the myocardium. During implantation, a stiffening stylet is employed to stiffen the lead body and a forceps is employed to grasp the electrode head to push the barb into the myocardium.
Over the years, endocardial pacing leads were improved by incorporation of effective active and passive fixation mechanisms, and development of simplified introduction procedures, stronger, more flexible, smaller diameter, and more reliable lead bodies enabling fixation of pace/sense electrodes in the right atrium, right ventricle and within the coronary sinus and great vein descending from the coronary sinus. Endocardial cardioversion/defibrillation leads were also developed incorporating these improved features of pacing leads and elongated cardioversion/defibrillation electrodes for implantation in the same locations. Thus, endocardial pacing and cardioversion/defibrillation leads have largely supplanted epicardial pacing and cardioversion/defibrillation leads in clinical practice. Epicardial pacing leads are still medically indicated for many patients, particularly children. Although the various indications for epicardial lead fixation in pediatric patients are numerous, some common factors include small stature, congenital heart defects with residual or potential right to left shunting or single ventricle hearts, or lack of venous access to the chamber requiring pacing.
Moreover, endocardial pacing and cardioversion/defibrillation leads cannot be implanted within the left heart chambers, due to risk of embolized thrombus. In particular, blood flows through the right heart chambers (atrium and ventricle), through the lungs, through the left heart chambers (atrium and ventricle) and then through the rest of the body, including the brain, before returning again to the right atrium. Implanted objects, however, often cause minor blood clots and thrombus to form in the blood. These may, on occasion, dislodge and be released into the bloodstream. Because the blood circulates directly from the left atrium and ventricle to the brain, any clots, however minor, could have serious consequences if they were to reach the brain, e.g. a stroke. In contrast, any clots released from an object implanted in the right side of the heart would simply travel to the lungs, where they would lodge, usually without serious risk. Consequently, endocardial leads are directed through the coronary sinus to locate pace/sense or cardioversion/defibrillation electrodes in the coronary sinus or great vein in order to pace and sense and/or cardiovert/defibrillate the left heart.
In spite of the difficulties, there remains a great need to be able to locate the electrode of a cardioversion/defibrillation lead at other left heart sites so that cardioversion/defibrillation shocks are delivered efficiently across the left ventricle.
Moreover, the left heart accounts for the majority of hemodynamic output. The left ventricle has a greater wall thickness (10-20 mm as compared to 1-5 mm) than the right ventricle because the left ventricle of the heart must pump oxygenated blood throughout the body while the right ventricle only pumps venous blood through the lungs to be oxygenated. Because the left heart is relatively more important for hemodynamic output, not surprisingly, various pathologies may be better treated through pacing of the left heart. For example, in patients with dilated cardiomyopathy and heart failure, electrical stimulation of both the right and left heart chambers has been shown to be of major importance to improve the patient""s well being and manage heart failure. See, for example, Cazeau et al., xe2x80x9cFour Chamber Pacing in Dilated Cardiomyopathy,xe2x80x9d PACE, November 1994, pgs. 1974-79. See also U.S. Pat. Nos. 5,716,392, 5,902,324 and 6,219,579 that provide right and left heart chamber pacing of heart failure patients.
As noted above, implantation of epicardial leads, is through general thoracic surgery; either via a median sternotomy; intercostal approach; or, in a more limited procedure, a sub-xiphoid approach. All of these procedures, however, involve major surgery, which may be painful and dangerous for the patient, as well as extremely costly. The sub-xiphoid approach, moreover, only permits limited access to the anterolateral surface of the left ventricle and does not provide any access at other locations of the left ventricle or the left atrium. A simpler, safer and more effective way of accessing the left side of the heart, including both the atrium and the ventricle with a medical electrical lead is needed.
The advent of thoracoscopy in cardiac surgery has shown promise as a technique to enable surgeons to implant epicardial leads without sternotomy or thoracotomy. Thoracoscopy normally involves penetration of the chest cavity with two or more tubular introducers that are passed through small incisions in the chest wall. Illumination devices, cutting instruments, sutures, etc. may be inserted into the chest cavity via the introducers. Approaches to accessing other sites of the left heart through the use of a thoracoscope and various tools are described in the above-referenced ""392 patent and in U.S. Pat. Nos. 5,871,532 and 5,464,447, for example.
The above-described, conventional, active fixation, epicardial leads utilize a widened mesh pad that is normally disk-shaped and that provides a stop to prevent further insertion of a screw or hook fixation mechanism and a surface to encourage tissue ingrowth that enhances chronic fixation. These disk-like pads may present the surgeon with certain difficulties during insertion via a typical thoracoscopy introducer. There is the potential for the suture pad to resist movement through the introducer, and the lead may be damaged in the insertion. To avoid the potential for snagging the lead, surgeons may have to use a larger than necessary introducer or trocar, resulting in a larger incision, more scarring, and potentially more post-operative pain for the patient.
To avoid these problems, the above-referenced commonly assigned ""392 patent discloses an epicardial lead having a xe2x80x9cski-shapedxe2x80x9d needle, a strand of between 1-5 cm attached to the needle, an electrode attached to the strand, and an insulated lead body attached to the electrode. In addition, a test wire is also attached to the needle to permit the electrical characteristics of tissue to be ascertained before the lead is fully inserted. In an alternate embodiment the strand may feature a fixation helix. Due to the shape of the needle and the relatively short strand, the lead is particularly suitable for implantation to a heart using minimally invasive procedures, such as trocar and a thoracoscope. However, the suturing remains complicated and difficult to perform through the trocar.
In the ""532 patent, an epicardial lead is disclosed having an active fixation mechanism for securing the electrode to the left heart that is introduced and deployed employing a thoracoscopy. A hook having a first longitudinally projecting piercing member is provided that has a first end that is pivotally coupled to a tubular housing that is coupled to the lead and has a lumen. A portion of the first end of the hook is disposed in the lumen, and the hook is pivotable between a first position wherein the first piercing member is disposed in spaced apart relation to the housing and a second position wherein the first piercing member is disposed proximate to the housing. A biasing member is coupled to the housing to bias the hook to the first position. The hook pivots to the second position in response to application of axial force to the portion of the first end to avoid piercing engagement with the heart, and pivots to the first position when force is removed so that the first piercing member of the hook may engage the heart.
The ""447 patent discloses the use of a thoracoscope to introduce epicardial cardioversion/defibrillation electrodes into engagement against the left ventricular epicardium and to surgically staple it in place. Access to the pericardium and heart is through small multiple opening sites (under 12 mm diameter) made in the chest and xiphisternal area. In particular, a subxiphoid opening, such as an incision or puncture, is used for insertion of defibrillator electrodes, while an opening, such as an incision or puncture, between the 2nd rib and the 6th rib of a patient is used for observation via a thoracoscope. The exact location of the incision or opening is dependent upon a patient""s particular anatomy. A trocar is inserted into the latter opening to facilitate the insertion and withdrawal of the thoracoscope and/or instrumentation. The defibrillator electrodes may also be manipulated through this latter opening. A third opening may be used for additional instrumentation and thoracoscopic observation as well as the later placement of a chest drainage tube. The defibrillator electrode is prepared for insertion by rolling it into a rolled shape with a pair of handles and then using the handles to insert the rolled defibrillator electrode through the latter opening or trocar. The defibrillator electrode includes a conductive wire mesh with a silicone backing, the silicone backing having a tail attached thereto. This allows the electrode to be pulled into place and then manipulated within the pericardium. The base of the tail can also be used as an attachment point for single point fixation. After proper placement of the electrode, permanent fixation with titanium staples is performed. In an alternative embodiment of a defibrillator electrode, a silicone insulator is positioned between a conductive wire mesh and a nonconductive mesh. A tail is attached to the nonconductive mesh.
Despite these improvements a need exists for a simple way to attach a pace/sense electrode of a pacing lead to the epicardium through a small diameter trocar or incision in a thoracoscopy where it is not necessary to manipulate the lead body or an active fixation mechanism.
Further epicardial pacing leads are disclosed in commonly assigned U.S. Pat. Nos. 4,282,886 and 4,768,523, wherein the fixation is effected by adhesives on the plate of the electrode head that polymerize upon exposure to body fluids and adhere with the epicardium. Cyanoacrylate surgical adhesive is employed in the ""886 patent, and hydrogels are employed in the ""523 patent. Hydrogels constitute a broad class of materials, which swell extensively in water but are not completely water-soluble. Partially dehydrated hydrogels, in which the hydrogel polymers contain controlled cross-linking, exhibit excellent adhesive properties, particularly in attaching to moist body tissue. The adhesive qualities of the hydrogels are affected by the degree of water content of the hydrogel. Aggressive adhesion develops during the initial phase of tissue contact when the hydrogel is hydrating or rehydrating.
Therefore, because these adhesives attach the plate to the epicardium upon contact, they prevent the testing of the optimal site of stimulation or sensing lead location. It is desirable to be able to press the pace/sense electrode against the epicardium and test the pacing and sensing thresholds before permanent fixation is effected, and that is not possible using such adhesives.
U.S. Pat. No. 6,121,341 discloses formation of a barrier over tissue or adhering tissues together or adhering implants to tissue in a process that involves applying or staining the tissue with a photoinitiator, then applying a polymer solution or gel (having added thereto a defined amount of the same or a different photoinitiator), and exposing the applied components to light to effect polymerization in situ. It is asserted that the delivered components polymerize at the tissue surface, adhere to the surface, and form a gel in the rest of the applied volume on exposure to light of a predetermined activation wavelength. Broad statements are made that electrodes and other implantable medical devices can be adhered to tissue in this way, but the only described examples relate to a polystyrene 12 plate or a Pellethane extruded polyurethane sheet. No other specific structures are disclosed.
This use of two-component adhesives delivered to the site requires a relatively complicated delivery system. Presumably, a useful delivery system would require delivery of precise amounts of each component in a fluid state that would have to mix together at the site. This would be difficult to accomplish without having direct visualization of the delivery, the mixing, and the light-activation.
Thus, there remains a need for a simple way of affixing an electrode to a surface of a body organ, e.g., the epicardium, in a secure and noninvasive manner.
Therefore, the present invention provides a novel lead having a noninvasive fixation mechanism and methods of and systems for attachment of an electrode of the lead to a surface of a body organ, e.g., the epicardium, in a noninvasive manner. The epicardial lead is preferably adapted to conduct electrical stimulation from an implantable or external electrical stimulator to a site of the epicardium and to conduct electrical signals of the heart from the site to the implantable or external electrical stimulator comprising an elongated lead body extending from a lead body proximal end to a lead body distal end, an electrode head formed at the lead body distal end having a plate adapted to bear against the epicardium, the electrode head supporting a first distal electrode, and a fixation mechanism comprising a light-activated adhesive disposed upon the plate that is sensitive to a predetermined bandwidth of light to adhere the plate to the epicardium while the plate is applied against the epicardium.
The lead is preferably implanted by performing a thoracoscopy of the thorax of the patient to visualize the site of the epicardium through a thoracoscope and to provide a pathway to the site of the epicardium. While viewing the site of the epicardium through the thoracoscope, the electrode head is inserted through the provided pathway to apply the plate against the site of the epicardium, and the light-activated adhesive is exposed to a predetermined bandwidth of light to adhere the plate to the epicardium.
The insertion is preferably conducted employing an elongated introduction tool having proximal and distal tool ends that is selectively operable to grasp and release the electrode head and to conduct light of the predetermined bandwidth to the electrode plate. The electrode head is grasped with the introduction tool at the introduction tool distal end and inserted through the second pathway to apply the plate against the site of the epicardium. The light of the predetermined wavelength or bandwidth is directed through the introduction tool to the electrode plate to activate the light-activated adhesive and adhere the electrode head to the epicardium. A release mechanism of the introduction tool is then manipulated to release the electrode head.
The introduction tool preferably has an opaque sidewall enclosing a plurality of optical fibers having optical fiber proximal and distal ends distributed around the circumference of and within the sidewall of the introduction tool to extend lengthwise to the introduction tool distal end, whereby the plurality of optical fiber distal ends are capable of emitting light of the predetermined frequency in a substantially cylindrical emission pattern from the introduction tool distal end.
The predetermined wavelength or bandwidth is preferably ultraviolet (UV) light. The light-activated adhesive is preferably coated upon the plate of the electrode head in a viscous or tacky form and enclosed within a light-tight package opaque to the predetermined wavelength or bandwidth in the final stage of manufacture to minimize exposure to any ambient UV light until the package is removed for use in the procedures of the present invention.
A second distal electrode can be formed on the electrode head or the lead body proximal to the electrode head.
The elongated lead body is preferably formed with a strain relief proximal to the electrode head for absorbing strain placed on the lead body at or adjacent to the lead body proximal end from being transmitted to the electrode head at the lead body distal end and absorbing the strain induced in the lead body by movement of the body organ, e.g., the contraction and expansion of the heart.
The strain relief preferably comprises one or more loop of the lead body formed in a common plane that is parallel with the plane of the mesh plate, so that the loops lie against the epicardium adjacent to and extending from the site of attachment of the electrode head to the epicardium.
This summary of the invention has been presented here simply to point out some of the ways that the invention overcomes difficulties presented in the prior art and to distinguish the invention from the prior art and is not intended to operate in any manner as a limitation on the interpretation of claims that are presented initially in the patent application and that are ultimately granted.